Reduction of Costs for Pelvic Exenteration Performed by High Volume Surgeons: Analysis of the Maryland Health Service Cost Review Commission Database

摘要

High volume hospitals (HVHs) and high volume surgeons (HVSs) have better outcomes after complex procedures, but the association between surgeon and hospital volumes and patient outcomes is not completely understood. Our aim was to evaluate the impact of surgeon and hospital volumes, and their interaction, on postoperative outcomes and costs in patients undergoing pelvic exenteration (PE) in the state of Maryland. A review of the Maryland Health Services Cost Review Commission database between 2000 and 2011 was performed. Patients were compared for demographics and clinical variables. The differences in length of hospital stay, length of intensive care unit (ICU) stay, operating room (OR) cost, and total cost were compared for surgeon volume and hospital volume controlling for all other factors. Surgery performed by HVS at HVH had the shortest ICU stay and lowest OR cost. When PE was performed by a low volume surgeon at an HVH, the OR cost and total cost were the highest and increased by $2,683 (P < 0.0001) and $16,076 (P < 0.0001), respectively. OR costs reduced when surgery was performed by an HVS at an HVH ($-1632, P 5 0.008). PE performed by HVS at HVH is significantly associated with lower OR costs and ICU stay. We feel this is indicative of lower complication rates and higher quality care. Pelvic exenteration (pe) was first introduced in 1948 by Brunschwig1 as a palliative procedure for advanced pelvic cancer. Presently, its indications have changed from palliation to cure. PE is indicated in primary rectal cancer that extends through the anterior rectal wall and invades the internal reproductive organs in locally recurrent rectal cancer; locally advanced cervical cancer; and persistent or recurrent endometrial, vaginal, vulva, anus, prostate cancer, or bladder cancer when these diseases involve organs in both the anterior and posterior pelvis. It involves en block resection of the pelvic tumor with all the invaded pelvic viscera, including the rectum, distal colon, urinary bladder, lower ureters, internal reproductive organs, draining lymph nodes, and pelvic peritoneum.